British nurses in behavioural psychotherapy: a 25-year follow-up

Naturalistic outcome of nurse-led psychological therapy for mental disorders in routine outpatient care: A retrospective chart review

This study aimed to investigate the clinical effectiveness of nurse-led cognitive/behavioral therapy (CBT) in Japanese routine outpatient care. We retrospectively collected data from 100 cases with mental disorders who had received nurse-led CBT. Results demonstrated that CBT provided by nurses led to significant improvements in quality of life and other clinical outcomes during the intervention period (all p < 0.001). Among participants who received optional follow-up, these improvements were well-maintained. This real-world evidence of nurse-led CBT bridges the research-practice gap, and will encourage frontline nurses and motivate institutional/organizational leaders, academic/professional societies, and policymakers to employ empirically-supported psychotherapeutic techniques in routine nursing care.

Cochrane reviews of educational and self-management interventions to guide nursing practice: A review

BACKGROUND

The burden of chronic disease on healthcare services worldwide continues to grow, and the increased development of educational interventions which help patients to better manage their own condition is evident internationally.

OBJECTIVES

This paper reports on findings of an updated review of Cochrane systematic reviews of interventions designed to improve patients' knowledge and skills to manage chronic disease, with particular reference to nursing contribution and practice.

METHODS

A broad search strategy was used to search the Cochrane Database of Systematic Reviews to identify reviews of patient education, self-management, and self-care studies. Two reviewers independently assessed eligibility for inclusion and extracted data from the reviews.

FINDINGS

From a total of 882 reviews, 63 met the inclusion criteria, and 900 studies were identified. Most (68%, n = 43) of the 63 reviews were judged by Cochrane reviewers to provide inadequate evidence of the effectiveness of the interventions reviewed. Information on the profession of the person delivering the intervention was often not available, although 78% (n = 49) of reviews mentioned that nurses were involved in a proportion of studies delivering interventions either independently or as part of a multi-professional team.

CONCLUSION

Educational programmes have definite benefits for patients suffering from asthma, chronic obstructive pulmonary disorder and stroke, and are promising in areas such as diabetes, epilepsy, cancer care, and mental health. However, it still is not clear what the active ingredients of many successful interventions are. Further research is needed to establish the impact of technology on programme delivery, and to develop programmes tailored for patients with multiple health problems.

Nurse-led group cognitive behavioral therapy for major depressive disorder among adults in Japan: A preliminary single-group study

Objectives

The prevalence and burden of disease of depression necessitates effective and accessible treatment options worldwide. Since April 2016, Japanese national health insurance has covered nurse-administered cognitive behavioral therapy (CBT) for mood disorders. However, empirical support for nurse-led CBT for depression in Asian countries, especially in Japan, is still lacking. This preliminary study aimed to examine the feasibility and acceptability of nurse-led group CBT for Japanese patients with depression.

Methods

In this single-arm study, we evaluated the effects of a 6-week group CBT, led by trained nurses, on patients with major depression. The primary outcome was the Beck Depression Inventory-II (BDI-II). Assessments were conducted at the beginning and end of the intervention.

Results

Of 25 participants screened, 23 were eligible for the study (of these, three dropped out during the trial but were included in the analysis). Nurse-led group CBT led to significant improvements in the severity of depression (BDI-II, P < 0.001). The mean total BDI-II score improved from 23.1 (SD = 7.56) to 12.4 (SD = 8.57), and the pre-to post-effect size was large (Cohen's d = 1.33). After CBT, 45% of the participants were judged to be treatment responders, and 34% met the remission criteria.

Conclusions

Our preliminary findings indicate that 6 weeks of nurse-led group CBT produced a favorable treatment outcome for individuals with major depression in a Japanese clinical setting. The results of this study might encourage more Asian nurses to provide CBT as a part of their nursing practice. Further controlled trials that address the limitations of this study are required.

Use of cognitive–behavioural therapy skills among trained psychiatrists

Aims and Method

Previous studies have suggested that despite the cost of attendance at postgraduate cognitive–behavioural therapy (CBT) courses, psychiatrists are unable to engage in CBT after qualification. A postal survey of psychiatrists with postgraduate CBT training currently practising in Scotland was performed to assess the levels of training and supervision that they provide, therapeutic CBT activity, and supervision and continued professional development that they receive.

Results

Of the 58 psychiatrists, 51 replied to the survey (88%). Less than half of the respondents supervised other staff. Although 43 (84%) engaged in some therapeutic CBT activity, only 25 (49%) received supervision for their own practice. The main reasons given for not engaging in CBT therapeutic activity were that there was inadequate ‘protected time’ and that CBT had not been included in ‘job plans'.

Clinical Implications

Psychiatrists can help to disseminate CBT skills. To do this, they require personal supervision, and time for the development and maintenance of therapeutic skills as well as for the training and supervision of others. This survey builds on the results of others and indicates that these requirements are currently being inadequately met.

Content Validity of a Psychotherapeutic Intervention Model in Nursing: A Modified e-Delphi Study

AIM

To estimate the content validity of a psychotherapeutic intervention model in nursing.

BACKGROUND

Mental health nurses encounter great extrinsic difficulties when it comes to providing psychotherapeutic interventions due to the fact that they are not allowed to perform such practice in some countries. In this light, the pursuit of a psychotherapeutic intervention model in nursing seems germane to guide the professionals' psychotherapeutic practice, contributing hereof to increase mental health nurses' professional autonomy.

DESIGN

Modified e-Delphi.

METHODS

Data were collected from October 2015 to January 2016 by means of three rounds of online questionnaires. The initial questionnaire was structured into five sections: general structure of the model, patients' exclusion criteria, assessment framework, nursing diagnoses, and nursing psychotherapeutic interventions. From the 42 experts invited, at least twenty (20) participated in each round.

RESULTS

The experts achieved consensus with regard to the conclusion that nursing psychotherapeutic interventions should always seek to address a nursing diagnosis. These defined furthermore that a psychotherapeutic intervention model in nursing should be exercised by means of 3 to 12 sessions using Nursing Interventions Classification (NIC) as a resource. Finally, experts deemed that the model should follow the principles of integrative psychotherapy, so that techniques from different schools of psychotherapy could therefore be used in conjunction to promote the resolution of a nursing diagnosis.

CONCLUSION

Achieving consensus about the structure of a psychotherapeutic intervention model in nursing is imperative to guide nurses in the provision of nursing psychotherapeutic interventions and to enable an effective evaluation of the health gains associated with its implementation.

Is investigator background related to outcome in head to head trials of psychotherapy and pharmacotherapy for adult depression? A systematic review and meta-analysis

Background

The influence of factors related to the background of investigators conducting trials comparing psychotherapy and pharmacotherapy has remained largely unstudied. Specializations emphasizing biological determinants of mental disorders, like psychiatry, might favor pharmacotherapy, while others stressing psychosocial factors, like psychology, could promote psychotherapy. Yet financial conflict of interest (COI) could be a confounding factor as authors with a medical specialization might receive more sponsoring from the pharmaceutical industry.

Method

We conducted a meta-analysis with subgroup and meta-regression analysis examining whether the specialization and affiliation of trial authors were associated to outcomes in the direct comparison of psychotherapy and pharmacotherapy for the acute treatment of depression. Meta-regression analysis also included trial risk of bias and author conflict of interest in relationship to the pharmaceutical industry.

Results

We included 45 trials. In half, the first author was psychologist. The last author was psychiatrist/MD in half of the trials, and a psychologist or statistician/other technical in the rest. Most lead authors had medical affiliations. Subgroup analysis indicated that studies with last authors statisticians favored pharmacotherapy. Univariate analysis showed a negative relationship between the presence of statisticians and outcomes favoring psychotherapy. Multivariate analysis showed that trials including authors with financial COI reported findings more favorable to pharmacotherapy.

Discussion

We report the first detailed overview of the background of authors conducting head to head trials for depression. Trials co-authored by statisticians appear to subtly favor pharmacotherapy. Receiving funding from the industry is more closely related to finding better outcomes for the industry’s elective treatment than are factors related to authors’ background.

Limitations

For a minority of authors we could not retrieve background information. The number of trials was insufficient to evidence subtler effects.

Mental health nurse prescribing: The research challenge

Nurse prescribing is gradually being implemented across a range of areas in healthcare. This paper examines the context of prescribing for mental health problems and discusses the issues relating to nursing and some of the broader matters such as the effectiveness of medication for mental health problems, the economics of mental illness and more general workforce issues. Mental health nurse prescribing obviously presents some significant research opportunities that should be seen within the settings of the Medical Research Council's framework for assessing complex health interventions (Campbell et al., 2000). The paper also considers some of the challenges of undertaking a randomised controlled trial for a topic within what Nancy Woolf (2000) describes as a 'socially complex service context'. Such a context requires the research team to consider a number of potential confounds. The paper concludes by suggesting some ways that such sources of confound be minimised.

What IAPT CBT High-Intensity Trainees Do After Training

BACKGROUND

The UK Department of Health Improving Access to Psychological Therapies (IAPT) initiative set out to train a large number of therapists in cognitive behaviour therapies (CBT) for depression and anxiety disorders. Little is currently known about the retention of IAPT CBT trainees, or the use of CBT skills acquired on the course in the workplace after training has finished.

AIMS

This study set out to conduct a follow-up survey of past CBT trainees on the IAPT High Intensity CBT Course at the Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London (KCL), one of the largest IAPT High Intensity courses in the UK.

METHOD

Past trainees (n = 212) across 6 cohorts (2008-2014 intakes) were contacted and invited to participate in a follow-up survey. A response rate of 92.5% (n = 196) was achieved.

RESULTS

The vast majority of IAPT trainees continue to work in IAPT services posttraining (79%) and to practise CBT as their main therapy modality (94%); 61% have become CBT supervisors. A minority (23%) have progressed to other senior roles in the services. Shortcomings are reported in the use of out-of-office CBT interventions, the use of disorder-specific outcome measures and therapy recordings to inform therapy and supervision.

CONCLUSIONS

Past trainees stay working in IAPT services and continue to use CBT methods taught on the course. Some NICE recommended treatment procedures that are likely to facilitate patients' recovery are not being routinely implemented across IAPT services. The results have implications for the continued roll out of the IAPT programme, and other future large scale training initiatives.

[Personnel resources for psychiatric institutions. Needs assessment exemplified by the nursing profession in Germany]

BACKGROUND

The Psychiatry Personnel Act (Psych-PV) as the basis for personnel assessment in psychiatry becomes invalid on 1 January 2019. Because the Psych-PV previously coupled the personnel quota with the intensity of services provided, current efforts are required to develop an instrument to adapt the extent of financed personnel resources to the manifold new legal requirements and advances in treatment in terms of guideline-based care.

OBJECTIVES

Based on a literature search and the additional use of a databank of routine data, an example of a calculation was made to estimate the additional personnel resources which would be necessary for psychoeducation and fulfill the legal requirements from 2019 onwards. An investigation was also carried out to identify which psychiatry guidelines contain time values which can be used for calculation of personnel requirements.

MATERIAL AND METHODS

A three-step approach was used: (1) screening of the current guidelines and determination of the average intervention times with respect to nursing staff, (2) exemplary comparison between the times for guideline-based psychoeducation for patients in the diagnosis groups F32-F33 with the times allocated by the Psych-PV and (3) determination of times between education measures prescribed by law and necessary training for which no (sufficient) time contingents are provided in the Psych-PV.

RESULTS

Times for individual activities (e.g. psychoeducation), which are also appropriate for nursing personnel can be found in the primary literature on guidelines; however, these include only a small proportion of tasks undertaken by nursing personnel. For psychoeducation it could be shown that additional time contingents would be necessary in the Psych-PV. Furthermore, there are new mandatory but disregarded schooling measures and instructions for nursing staff, the duration of which can be conservatively calculated as 21 min per case per hospital stay.

CONCLUSION

The empirical approach presented in this study shows the possibility to identify time resources needed for nursing personnel to provide guideline-based interventions; however, these represent only partial aspects of nursing activities. Further research and analytical methods are needed to calculate the currently needed personnel resources for all nursing activities and other professional groups involved in treatment in inpatient psychiatry.

Cognitive Behavioral Therapy in Psychiatric Nursing in Japan

Psychiatric nurses have played a significant role in disseminating cognitive behavioral therapy (CBT) in Western countries; however, in Japan, the application, practice, efficiency, and quality control of CBT in the psychiatric nursing field are unclear. This study conducted a literature review to assess the current status of CBT practice and research in psychiatric nursing in Japan. Three English databases (MEDLINE, CINAHL, and PsycINFO) and two Japanese databases (Ichushi-Web and CiNii) were searched with predetermined keywords. Fifty-five articles met eligibility criteria: 46 case studies and 9 comparative studies. It was found that CBT took place primarily in inpatient settings and targeted schizophrenia and mood disorders. Although there were only a few comparative studies, each concluded that CBT was effective. However, CBT recipients and outcome measures were diverse, and nurses were not the only CBT practitioners in most reports. Only a few articles included the description of CBT training and supervision. This literature review clarified the current status of CBT in psychiatric nursing in Japan and identified important implications for future practice and research: performing CBT in a variety of settings and for a wide range of psychiatric disorders, conducting randomized controlled trials, and establishing pre- and postqualification training system.

Cognitive behavioural psychotherapy graduates in Ireland: a follow-up survey of graduates from an Irish university

BACKGROUND

Training in cognitive behavioural psychotherapy (CBT) is expensive both for the students and their funding bodies.

OBJECTIVES

It is important to know how graduates of CBT courses are putting their skills to use, and whether they are continuously updating those skills to achieve best practice. We also wanted to discover the similarities and differences between CBT trainees in the United Kingdom and in the Republic of Ireland (courses in the United Kingdom being analogous to those in Ireland in content and participants).

METHOD

An internet survey, derived from previous postal questionnaires, was used to enquire into the practice, experience, and continuing professional development of graduates from the CBT courses at Trinity College Dublin.

RESULTS

Most MDT professions were represented in the graduates, preponderantly psychiatrists and mental health nurses, but also including social workers and occupational therapists. Most participants believed that the course had enhanced their careers, and almost half had changed job since graduating. Half said that CBT was now the main focus of their job, but others reported lack of resources, funding, time, and other duties impeded their ability to conduct CBT with clients. However, most participants engaged in continuous professional development regarding CBT, and received CBT clinical supervision. Discussion There was a difference in the proportion of the different professions undertaking this course compared with the United Kingdom and our response rate here was significantly lower. As in UK surveys, participants who may have been supported and funded to undertake the training may not afterwards be supported in implementing their skills in the workplace. The broader implications of this are discussed.

A systematic review evaluating the impact of post-registration nursing and midwifery education on practice

Given the current focus on evidence-based practice, it is surprising that there is a dearth of systematic evidence of the impact on practice of post-registration nursing and midwifery education. The systematic review presented here formed part of a national review of post-registration nursing and midwifery education in Ireland [Health Service Executive, 2008. Report of the Post-registration Nursing and Midwifery Education Review Group: Changing practice to support service delivery. Health Service Executive, Dublin]. The review focuses specifically on the impact on practice from the perspective of nurses, midwives, patients, carers, education and health service providers. Sixty-one (61) studies met the criteria set. These studies were mainly of a retrospective and descriptive nature, often with small cohorts, set within one educational setting. The findings indicate that students benefit from post-registration programmes in relation to changes in attitudes, perceptions, knowledge and in skill acquisition. There is also some evidence that students apply their newly acquired attitudes, knowledge and skills. There is however limited evidence of the direct impact on organisational and service delivery changes, and on benefits to patients and carers. It can be concluded that the impact of post-registration nursing and midwifery education on practice has yet to be fully explored through a more systematic and coherent programme evaluation approach.

Can training community mental health nurses to support family carers reduce behavioural problems in dementia? An exploratory pragmatic randomised controlled trial

BACKGROUND

Community mental health nurses (CMHNs) are the backbone of specialist mental health services in the UK. This study evaluated the effects of training CMHNs in a systematic psychosocial intervention (PSI), to help family carers manage behavioural changes in their relative with dementia.

METHOD

One hundred and thirteen family carers received PSI support from a 'trained' (experimental), or a 'usual practice' (control) CMHN. Primary (day-to-day behaviour problems and management) and secondary (carer mood) outcome measures were obtained at baseline, 6, 12 and 18 months. CMHN training and supervision commenced prior to, and continued throughout, the 18-month study.

RESULTS

Patient cognition declined in both groups, but problem behaviour reduced in experimental group families. However this effect was associated with the practice of some, not all, CMHNs. Carer management and mood improved with PSI support. In contrast, by 18 months, families supported by conventional CMHNs reported reduced coping resources, increased problem behaviour and their level of depression worsened. Only two CMHNs adhered to the PSI-protocol.

CONCLUSIONS

Some, but not all, 'trained' CMHNs used the PSI to help family carers reduce behavioural problems. A relatively long but not intensive PSI of 12-18 months was needed to moderate carer mood. Dementia-specific practice arrangements, training and sustained clinical supervision are important for the delivery of effective psychosocial interventions in dementia.

Self-esteem and self-acceptance: an examination into their relationship and their effect on psychological health

Nurses are increasingly using cognitive behaviour therapy as an intervention for psychological problems attached to a variety of clinical conditions. Developing both self-acceptance and self-esteem have been identified as ways to enhance cognitive interventions. However, there are disagreements about the relationship between self-esteem and self-acceptance and their influence on psychological health. The study examined the relationship between these concepts and also the association between the concepts and psychological health. Fifty-eight participants with a diagnosis of severe and enduring mental health problems were assessed recording levels of self-esteem, self-acceptance, depression, anxiety and psychological well-being. The results revealed that, in comparison with the general population, the sample were more likely to have lower self-acceptance and self-esteem, and higher levels of anxiety, depression and psychological ill health. The concepts of self-esteem and self-acceptance were found to be similar but not synonymous. Self-esteem was more closely associated with affect, with higher levels of self-esteem being indicative of lower levels of depression. Self-acceptance appeared to be more closely associated with general psychological well-being and to be more helpful when undertaking clinical work for general psychological problems.

Rethinking mental health nursing education in Australia: a case for direct entry

Desperate times call for creative solutions. The mental health workforce shortage has created an opportunity to rethink current and future education and training needs in order to prepare competent and compassionate practitioners to meet the changing demands of consumers and their carers requiring mental heath treatment and support. This article urges consideration of an undergraduate direct entry mental health programme similar to that of midwifery or the nursing foundation/mental health branch programmes of the UK.

A survey of trainees' opinions and current clinical practice after behaviour therapy training

The widespread use of cognitive behaviour therapy principles in psychiatric/mental settings has been an ongoing feature of health and social care since at least the 1960s. The current study evaluated the training process as well as the use of the skills by course participants on a dedicated behaviour therapy course in Ireland. A cross sectional study was undertaken, using postal distribution of a questionnaire based on a similar study undertaken in the UK. The sample comprised all graduates of the course from 1986 to 1999 (N = 257). Thirty-three per cent of respondents report using their behaviour therapy skills to a high level since completion of the course. Approximately 53% of respondents reported having changed job since completion of the course. Significant differences emerged within this group in relation to their ratings of the importance of various elements of the course and also in relation to the perceived enhancement of both general clinical skills (P = 0.000) and specific behaviour therapy skills (P = 0.000) as well as the rating of current skills (P = 0.015) and the respondents' use of behaviour therapy since completing the course (P = 0.015). While a high proportion of participants had some prior theoretical or experiential exposure to behaviour therapy, the findings report high satisfaction levels with the training they received. However, the survey signals deficits in terms of the usage of the skills. While on the one hand, the general and specific skills acquired while on the course seem to transfer quite easily across functions and levels of responsibility, it is of concern that over a 13-year period, only 17% of respondents indicated that behaviour therapy was the main focus of their work. The implications of these findings are discussed in relation to policy and practice issues.

The effectiveness of advanced practice registered nurses as psychotherapists

This article explores the effectiveness of advanced practice registered nurses as psychotherapists. Psychiatric/mental health (PMH) clinical nurse specialists (CNSs) possess the training, skills, and abilities necessary to provide effective psychotherapy. A case study is examined involving a client with obsessive-compulsive disorder who underwent psychotherapy by a PMH CNS graduate student. Evidence is presented that CNSs follow evidence-based procedures with effective outcomes.

Is training in psychosocial interventions worthwhile? Report of a psychosocial intervention trainee follow-up study

A follow-up study of psychosocial intervention (PSI) trainees from the Sheffield and Maudsley training centres was undertaken in three stages. In Stage 1, 141 students, at two PSI training centres, were sent a simple postal questionnaire to elicit career trajectory following PSI training. A response rate of 82% was achieved. The sub-group, who had been trained and who still engaged in clinical practice were identified and followed-up in more detail (n=96). The effect of PSI training in a range of domains was investigated. The impact of training may not be to equip students with formal technical skills in CBT and family work. What is more likely is that trainees acquired proficiency in: working effectively using a case management model; conveying 'therapeutic optimism'; enabling users to meet their own goals and helping them to develop better coping strategies; using 'stress vulnerability' and formal outcome measures as means of structuring this approach. The secondary aim of the study was to identify and prioritise the barriers that impede the effective implementation of PSI skills in routine service settings. For the second phase of the survey the response rate was again 82%. This group's service managers were identified and surveyed for the same information and 59% responded. The aim was to gather information about implementation issues from both the clinical and service perspectives. The results of the survey indicate that PSI training has a positive impact on the development of services for people with serious mental health problems although there are serious organisational hurdles for managers, trainees and organisations to overcome if PSI skills are to be properly implemented. Key factors that impact upon faithful implementation are related to resource issues (caseload size), organisational factors (the existence of an implementation plan and training strategy), and the extent to which the trainee's team is supportive.